Prostate Cancer Screening Update

Aug 2014

The European Randomised Study of Screening for Prostate Cancer (ERSPC) is the biggest and best organised international study of Prostate Specific Antigen (PSA) based screening. Its latest results show that after 13 years of testing at 2-4 year intervals, men aged 55-69 can expect a 27% reduction in the likelihood of death from prostate cancer (PCa) compared to unscreened men (The Lancet, Early Online Publication, 7/8/14).

The same authors have further analysed statistics from nearly 35,000 men in the Rotterdam cohort of the ERSPC and concluded that PSA based screening “can reduce the risk of dying from PCa up to 51% for an individual man choosing to be screened repeatedly compared with a man who was not screened” (European Urology 65; 2014; 329-336).Although this is more than the benefit of breast cancer screening and bowel cancer screening, the authors still do not recommend population-based screening due to the perceived risks of “over treating” non-aggressive PCa that would never cause death.This risk of “over treatment” has been set at 40% with attendant complications of impotence and incontinence.Is this caution justified?

Although there is no inexpensive alternative to PSA as a first-line guide, the diagnostic pathway for UK men with suspected, early, curable PCa has improved considerably.There is no longer a need for automatic, invasive, prostatic biopsy whenever the PSA is raised.Instead, additional information such as the amount of Free PSA and the ratio to Free to Total PSA is taken into account and when combined with the new second line marker hK2, can accurately predict the likelihood of an underlying cancer.Crucially, it can predict the likelihood of any cancer being aggressive or non-aggressive.In addition, MRI scans are far superior to ultrasound and are now used routinely to look for PCa and, if present, allow precise, targeted biopsies to take place rather than the previous random biopsy technique.

Given that PCa is the commonest cancer in UK men at 40,000 new registrations every year with the second highest death rate at nearly 11,000 each year, what pragmatic steps can be taken to address this unacceptable situation against the current background of anti-screening rhetoric?We advocate the following steps:

None of these steps is rocket science and neither do they incur excessive costs but only when these steps have been adopted on a national scale are we likely to see a substantial fall in our woeful and unnecessary death rate from this commonest male cancer.

Chris Booth